Joint

An ankle injury is the most common type of injury that may involve the bones of the ankle and other soft tissue structures. Three are three types of injuries that are observed at the ankle:

Sprains

Strains

Fractures

Sprains are injuries to the ligaments that connect one bone to another. An ankle sprain may involve an injury to one or more ligaments that stabilize the ankle and the foot.

Strains are injuries that involve musculotendinous (muscle and tendon) structures. Both sprains and strains can occur due to over-stretching or tearing of the ligaments and tendons due to sudden twisting of the ankle joint or when excessive forces are applied on them.

Fractures are injuries that involve bones of the ankle joint. It ranges from a simple break in one bone to several fractures, which causes your ankle to move out of place and puts you in great pain.

This is the most common injury to the ankle. Often, an inversion sprain could be an associated with a fracture and a strain to the peroneal tendons.

An inversion sprain happens when the ankle in twisted inwards with an inward rolled foot as shown in Fig 1.

Fig 1: Lateral ankle injury

The Medial ankle injury

This type of injury occurs at the inner aspect of the ankle. Like a inversion sprain, the eversion sprain may also be associated with fractures of lower ends of the leg bones and strains to the tibialis anterior muscle.

Eversion sprain happens when the ankle is twisted out with the foot rolled outwards as shown in Fig 2.

Fig 2: Medial ankle injury

High Ankle Injury

This type of injury is very rare. A high ankle sprain happens when the tibia bone rotates injuring the ligaments that hold the lower end of the two leg bones (tibia and fibula) as shown in Fig 3.

Severe injuries may cause fracture to the lower ends of the leg bones.

Fig 3: High ankle injury

Severity of an ankle sprain

An ankle ligament sprain can be graded according to the severity of the tear in the ligaments as shown in Fig 4.

Fig 4: Grades of ankle sprain

Sign and Symptoms of Ankle Injury

Swelling: Increased fluid in the tissue due to inflammation and soft tissue damage.

Pain: Depending upon the severity of the injury and the structures involved, pain intensity can vary.

Unstable ankle: The affected side feels weak and difficult to weight-bear.

Deformity: Severe injuries can cause fractured bones to move out of place and make the ankle look deformed.

Causes of Ankle Injury

Trauma

Stepping in a hole or a stone

Running on uneven ground

Fall or slippage on wet floor

Contact injury during sports like basketball, when a player is accidentally hit by an opponent causing the foot to roll inwards as shown in Fig 5.

Fig 5: Lateral ankle sprain during basketball

Muscle imbalances

Lack of flexibility in muscles can hamper joint movement. For example, if the calf muscles are very tight, it will affect the stability and mobility of the ankle joint. In such a state, if one engages in any physical activity like running there could be a potential risk of twisting an ankle. Sometimes even lack of warm-up and stretching could be the cause of muscle imbalances.

Lack of Postural control

Postural control is defined as the act of maintaining, achieving or restoring a state of balance during any posture or activity.

It helps to maintain a good base of support for balance so that the force of gravity can act on the center of mass (COM) of the body. Centre of mass is the point in the body where the entire body weight is concentrated (located in the lower end of the spine) as shown in Fig 6.

Fig 6: Line of gravity and base of support

During sports, sudden quick body movements or external forces like a push or a contact by an opponent will affect your balance. If you lack postural controlm you may lose balance and risk hurting your ankle.

Diagnosis of an ankle injury

Most ankle injuries are usually straightforward ligament strains. However, the clinical presentation of subtle fractures can be similar to that of a ankle sprains and these fractures can be easily missed on initial examination. Fractures are usually detected via X-ray scans. If any fracture is left untreated, it may cause excessive pain and disability to an extent that youmay not be able to bear weight on the joint. Therefore, an X-ray or an MRI scan is often recommended to understand the severity of the injury.

For example, a lateral ankle sprain showing fractured bones in an X-ray is shown in fig 7.

Fig 7: Lateral ankle sprain with fracture of the lower end of fibula bone

Ankle Injurymanagement

Usually, ligament injuries heal in about 6-12 weeks and fractured bones take about 3-6 months to heal. This is however largely dependent on the severity of the injury and lifestyle of the individual so complete healing time frame may vary.

Even after the healing process, ankle injuries may cause long term instability if not healed correctly. This may also be the cause of recurrent ankle sprains. An expert assessment of ankle mechanics is very important to decide on how long to protect and rehabilitate an ankle after an injury. The treatment plan will aim to restore the normal functions of the ankle and make return-to-play decisions based on the stability of the ankle thus preventing recurrent ankle injuries.

The temporomandibular joint (TMJ) or the jaw joint is a synovial hinge type of joint. This joint is responsible for the movements of our mouth that are needed for chewing, biting, talking and yawning.

To achieve the complex movements needed by the jaw, the TMJ has two articulating surfaces which include the head of the mandible (jaw bone) that fits in the articulating socket of the temporal bone of the skull. In order to prevent friction between the two bones, an articular disc sits between the articulating surfaces which moves with the head of the mandible as one unit.

Fig 1: Normal TMJ when jaw closed

Apart from the disc and articulating structures, there are other supporting structures that provide stability to the TMJ:

Joint Capsule

Ligaments

Muscles

Joint capsule and Ligaments of the TMJ

The capsule is a fibrous cartilaginous membrane that along with the ligaments surrounds the TMJ and attaches all around the articular eminence of the temporal bone, the articular disc and the neck of the mandibular condyle. Both the capsule and the ligaments provide stability to the TMJ during movements. The four ligaments include (Refer Fig 2),

Individuals who have misaligned jaw or teeth which are hereditary can be affected with TMJ disorder.

Functional mandibular overload

Normally the jaw is free to move and make contact with the teeth in the right position, (centered occlusion), in anatomical and functional harmony.

Mandibular overload occurs when one sleeps in a wrong position (face down) where the load of the head pushes the mandible to compress the TMJ on one side and attenuation of the ligaments on the other side. Compression obstructs the blood circulation and moves the teeth to a lateral bad occlusion position. In such a situation, swallowing causes the masticatory muscles to overwork to centre the jaw and bring the teeth from forced lateral malocclusion to centred occlusion. This causes a disharmony between the upper and lower teeth. An imbalance of the jaw that can cause bruxism in an attempt to re-position the teeth.

The term bruxism is defined as an involuntary rhythmic or spasmodic non-functional gnashing, grinding or clenching of teeth. The rubbing causes tooth facet to wear out, structural and function damage to the capsulo-ligamentous and muscles around the TMJ. Stress and psychological problems could worsen the condition.

Sudden trauma

Whiplash injury occurs any time when the head is suddenly and unexpectedly distorted from the neck, causing overstretching of the muscles and ligaments that hold the neck and head in alignment. During a whiplash injury, there is also a potential secondary injury of whiplash in the jaw. Jaw dislocation in severe cases can also occur.

Inflammatory diseases

Sometimes infection in the teeth or adjacent structures can cause a spread of infection in the TMJ leading to infectious arthritis.

TMJ could also be affected by osteoarthritis that causes damage in the articular cartilage of the joint and disc degeneration leading to friction between the bones causing inflammation and pain. It usually affects individuals above 50 years of age and is associated with trauma and other muscular and teeth problems.

TMJ disorder could also be present among individuals who are already diagnosed of rheumatic arthritic disease.

Symptoms of TMJ

Jaw pain: Pain and tenderness in the jaws. Increasing pain during chewing in the TMJ and in the muscles, radiating pain is also felt in the face, jaw, or neck.

Limited or painful jaw movement: Swelling due to the inflammation lead to joint stiffness and limited movement, wear and tear of the disc leading to locking of the jaw and impaired jaw function.

Headache, Neck pain or stiffness: It is generally assumed that headache, neck pain, or painful jaw movement is suggestive of muscular problems. Masticatory and neck muscles may show muscle spasm and myofascial trigger points in the masseter or sternocleidomastoid muscles that refer pain to the head.

Clicking or popping: This occurs within the joint during mouth opening and may indicate displacement of the intra-articular disk during mandibular movement.

Ear pain and tinnitus (Ringing of the ear): Middle ear muscles have a common embryological and functional origin with masticatory (Chewing muscles) and facial muscles.Having said that, problems with muscles in TMJ disorder could affect the middle ear. In case, other ear problems are not the cause of ear pain and tinnitus a temporomandibular joint dysfunction may be the reason of these symptoms.

Prevention and Treatment

In order to relieve pain and restore the function of the TMJ, a thorough assessment is required to correctly determine the causative factors and to treat the involved structures. Personalized care interventions at an early stage that includes behavioural change and reassurance are important steps for prevention of TMJ disorder.

Like this:

The main joint of our upper limb is the shoulder joint which can be moved in various positions when looked at in a three-dimensional perspective. In order to be able to have these movements, many other components help in order to maintain a stable shoulder. In short, there is a complex interplay between the shoulder joint, other joints, muscles and ligaments that make the shoulder a complex and unique part of our body.

The shoulder joint (GH) is made of two main bones that articulate with each other forming the ball and socket joint. The ball of the arm bone(humerus) and the glenoid cavity of the shoulder blade(scapula) is articulated at the shoulder joint (GH joint). Similarly, on the inner chest, the clavicle articulates with sternum to form the SC joint while on the outer end towards the shoulder the clavicle articulates with the acromion process of the scapula bone to form the AC joint. Both GH, SC and AC are true joints with union by fibrous, cartilaginous or synovial tissues. Lastly the ST joint, while this is not a true bony joint, its muscular attachments create a shoulder joint complex.

The humeral head (ball) is about three times larger than the glenoid fossa. Actually, only 25 percent of the humeral head articulates with the glenoid fossa. Glenoid cavity (fossa) forms a very shallow socket as compared to the hip socket of the hip joint. Therefore, the humeral head articulates with a smaller open and shallow saucer- type of articulation, lacking stability in its own. However, it is with all the soft tissue structures both inside and outside the joint that are responsible for the overall stability of the arm during movements.

Soft tissue structures that support the Shoulder Joint

The important soft tissue structures are:

Articular Cartilage

Labrum

Joint Capsule

Ligaments

Muscles

Articular Cartilage

A smooth, white tissue that covers the humeral head (ball) and the glenoid fossa to make it easier for the two bones to move at the joint. It allows the bones to glide over each other with very little friction.

Labrum

Since the head(ball) of the upper arm bone is larger than the glenoid fossa, the articular cartilage forms a soft fibrous tissue rim called the labrum which surrounds the socket to help fit the head into it thus stabilizing the joint.

The socket can be divided into four regions namely anterior (front), posterior ( back), superior (the upper end near your head), and inferior (the lower end which is towards the elbow). Based on these regions the labrum is also called as superior, inferior, anterior and posterior labrum.

Joint Capsule

The shoulder joint capsule is a membranous sac that encloses the entire joint. The joint capsule of the shoulder is attached along the outside rim of the glenoid labrum of the glenoid cavity and attaches to the neck of the arm bone. The capsule by itself is quite loose and it is the surrounding reinforcement by the muscles, tendons, and ligaments that are largely responsible for keeping the shoulder joint stable.

Ligaments

In the shoulder, there is a group of ligaments that is responsible for the stability of the shoulder.

Glenohumeral Ligaments (GHL)

This ligament attaches from along the outer glenoid socket covering the joint to the upper part of the arm bone.

Superior (upper) GHL

Middle GHL

Inferior (lower) GHL

Coraco-acromial Ligament (CAL)This ligament attaches from the coracoid process to the acromion process of the shoulder blade (Scapula).

Coraco-clavicular Ligaments (CCL)These two ligaments (trapezoid and conoid ligaments) attaches from the clavicle to the coracoid process of the scapula. This ligament can carry the load and is extremely strong. These tiny ligaments (with the AC joint) keep the stability between the scapula and the clavicle and thus keeping your shoulder ‘square’.

Transverse Humeral Ligament (THL)

This ligament protects the long head of biceps tendon muscle in the groove of the arm bone.

Muscles for the stability of the Shoulder Joint

Muscles of the shoulder connect the shoulder girdle, the clavicle and arm bone.

Muscles that origin from the spine and attaches to scapula and/or clavicle

Muscles that origin from the clavicle or scapula and/or body wall(ribs) to the top end of the humerus.

Trapezius, Levator scapulae, Rhomboids and Serratus Anterior

Originate from the base of the skull and/or spine and connect the scapula and clavicle to the trunk of the body.

Trapezius forms cross-shaped web along the neck and run from the spinal column out to the shoulder blade and clavicle bone. It helps to shrug the shoulders.

Rhomboids and levator scapulae are important muscles that join the shoulder blade to the spinal column helping the scapular movements.

Serratus anterior muscle helps to stabilize the shoulder blade on the chest wall. When this muscle is weak, winging of the scapula occurs which is when the shoulder blade protrudes from the back.

These arise from the clavicle and/or scapula and/or body wall and connect to the upper end of the arm (humerus) and anchor the shoulder joint to our body.

Deltoid muscle is a muscle that is responsible for overhead activities. It helps to move the arm sideways up.

Pectoralis major muscle like the deltoid is another powerful muscle which is the main muscle when doing push-ups. It originates from the front of the chest and collar bone and inserts on the upper part of the arm bone (humerus).

Latissimus dorsi is another powerful muscle that together with the teres major muscle pulls the arm down to the side. We use this muscle when doing chin-ups.

What are the Shoulder blade movements?

The muscles of the shoulder complex work together to perform a particular action. The Scapula and arm bone move together in a pattern to perform a movement.

The movements of the Scauplo-thoracic joint includes,

Depression – Downward arm and shoulder girdle movement

Elevation – Upward arm and shoulder girdle movement

Retraction – backward shoulder girdle movement

Protraction – forward shoulder girdle movement

Rotator cuff muscles- small in size, big in importance

The four rotator cuff muscles are important for the stability and movements of the shoulder joint. They are,

Subscapularis

Supraspinatus

Infraspinatus

Teres minor

These muscles connect the shoulder blade (Scapula) to the arm bone (Humerus) supporting the entire shoulder joint during movements.

The major function of the four rotator cuff muscles is to work simultaneously with each other to allow the arm to move freely in numerous positions. They do all this while pulling the humeral head downward and inward within the glenoid fossa.

Movements at the shoulder joint

The main movemnts at the GH joint are:

Flexion-Extension

Abduction-Adduction

Internal and External rotation

Supraspinatus assists with lifting the arm with the deltoid above the head (abduction). This is the most common muscle / tendon to tear in the shoulder.

Subscapularis twists the arm behind (Internal rotation) the back.

Infraspinatus and the teres minor twists the arm outwards(External rotation) and sideways from the body.

In order to prevent upward dislocation of the arm or tear within the inner soft tissue structures like labrum and capsule of the shoulder, balanced rotator cuff strength and function are necessary. All the rotator cuff muscles work together stabilizing the humeral head within the glenoid while the larger muscles like the ltissimus dorsi, pectoralis major and deltoid produce the forces necessary for movements.

Common Injuries to the shoulder

Broken collar bone (Clavicle)

Dislocations of the shoulder

Frozen shoulder (Adhesive capsulitis)

Rotator cuff injury or strain (tendonitis or tendinopathy)

Acromioclavicular joint sprain

SLAP Tear (Superior Labrum Anterior Posterior tear)

Bankart’s lesion (Anterior inferior Labral tear, sometimes a part of the genoid cavity bone is also broken)

Most injuries to the shoulder are due to sudden trauma or repetitive trauma to the soft tissues and bones. Some of the injuries occur because of improper exercise selection, faulty technique, lack of warm-up, lack of dynamic stretches, dehydration and many more. However, knowing the anatomy and functions of the joints and soft tissue structures of the shoulder complex not only gives you a better understanding of it but will possibly give you a prospective as to how important is their role in maintaing the stability of the shoulder.

Our joints are responsible for movements and stability (e.g ability to maintain and control movements in your knees). Different joints have varying degrees of inherent stability considering its function, the way it articulates, anatomical position, load-bearing capacity, strength and flexibility of the soft tissue structures (muscles, ligaments, and fascia).

Joint mobility, on the other hand,refers to the range of movement in a particular joint. Like stability, it is dependent on the strength and flexibility of the surrounding soft tissue structures. This means that any problems with the soft tissue structures would affect the stability and mobility, making the joint susceptible to injuries and dislocations.

Hypermobility

You are said to be ‘hypermobile’ when you have the ability to move your joints beyond the normal range of movement. Sometimes it’s also called ‘double-jointed’. This condition is fairly common in the general population and might sometimes become an advantage for athletes or dancers.

Having said that, there are different problems related to hypermobility. The most important being the lack of stability in the joints. One may be predisposed to soft tissue structure injury and experience excessive muscular stiffness.

‘Hypermobility’ – How did I get so flexible?

Genetics – Connective Tissue Disorder

The exact cause is unknown. Due to genetic problems, it can be seen among infants at birth with sometimes a possible decline in hypermobility during childhood, teens and adulthood. An improper gene resulting in joint laxity is due to the lack of collagen, elastin and fibrin proteins which usually help with the stability of joints, tendons and ligaments.

Acquired hypermobility

Without having inherited laxity in the joints, many ballet dancers and gymnasts get hypermobile as they push the joints to the hypermobile range while working to get the flexibility to perform. Intense and excessive stretching of the muscles and soft tissue structures can also lead to hypermobility.

When do we say you have a Hypermobility Syndrome?

Joint Hypermobility Syndrome (JHS)

Individuals who suffer from chronic joint pain and other symptoms related to their hypermobility have a condition called joint hypermobility syndrome (JHS). As the name suggests the most affected part is the musculoskeletal system.

Due to hypermobility, the risk of injury to the joint structures, ligaments, tendons and other ‘soft tissues’ around joints are increased. In addition, the structure of the collagen fibres and the shape of the bone (articulating surfaces) both play a major role. Even a lack of neuromuscular tone and proprioception could be the contributing factors to this condition.

Aggravating factors, Symptoms and Common conditions associated with JHS

There is no specific activity that can trigger pain. For some individuals, repetitive movements, overuse, excessive weight bearing or even simple activities of daily living can cause pain.

Incorrect posture and alignment of joints: During daily or sports activities incorrect movements due to faulty posture can affect the hips, shoulders, knees, and elbows joints. For example, hyper-extending the elbows can injure the tendons on the sides of the elbow causing conditions like “tennis elbow” and “golfer’s elbow.”

Laxity in the soft tissue structures: This leads to increased strain, tearing and spasm causing pain and stiffness around the joint. Due to over extending and twisting flexible joints, partial dislocations or complete dislocation can also occur.

Muscle imbalances: Pain due to injury causes adhesions withing the soft tissue structures (Muscles, ligaments and fascia) of one joint leading to imbalances in the mobility of other joints and surrounding structures. Pain and spasm of the hip muscles can pinch the sciatic nerve resulting in pain called as sciatica which can be felt radiating down the back to the leg. Sometimes it could also be because of the inter-vertebral discs (made of collagen) that has become too soft than normal and has impinged the nerve.

Stretching: Incorrect technique or type of stretching that involve grabbing a joint and pulling or pushing on it to loosen it up.

Heavy lifting,pullingand pushing: Odd-shaped weights and unusual angles often lead to injury due to excessive load on the joints.

Recurrent Ankle sprains: Sprains may take very longer to heal because they tend to get injured repeatedly while trying to heal.

Knee pain: This is most common in hypermobile. People because the cartilage between the kneecap and the knee get lax. Due to excessive mobility, the cartilage underneath the kneecap starts to wear down (a condition referred to as chondromalacia), causing pain and sometimes a crunching or grinding noise – while kneeling, squatting or climbing the stairs.

Chest pain: A condition called costochondritis or inflammation of the rib cartilage causing pain and tightness.

The jaw, or temporomandibular joint (TMJ): This is often affected because of loose structures.

Although pain and fatigue are the common complaints, the range of symptoms could be wider considering that cardiovascular and endocrine system could also be affected.

Are my symptoms related to Pain and Fatigue syndromes or is it because of Joint Hypermobility Syndrome?

Hypermobility predisposes people to developing Chronic fatigue syndrome (CFS), Fibromyalgia (FM), Chronic Regional Pain Syndromes (CRPS), Chronic Widespread Pain (CWP). In simple words, someone with hypermobility may have other pain and fatigue syndrome. However, people with pain and fatigue related syndromes may not be hypermobile. Thus, a careful diagnosis is necessary.

Hereditary Syndromes associated with JHS

Marfan’s syndrome or Ehlers-Danlos syndrome, Osteogenesis Imperfecta: These are usually inherited disorders that are passed on to children by their parents. Often, children with Down syndrome will also be hypermobile.

Diagnosis of Joint Hypermobility Syndrome and Management

In some cases, people may have inflammation in their joints but no presence of abnormalities of their blood tests (so called seronegative inflammatory arthritis). Similarly, confusion is very common among clinicians to come to a particular diagnosis with the number of pain and fatigue syndromes associated with the joint hypermobility syndrome.

Most clinicians use the Beighton score which is a nine-point scoring system that looks for hypermobility. In the thumb, elbow and knee on both sides of the body and the ability to bend forward and place the palms of the hands flat on the floor without bending the knees. Hypermobility is often found at the jaw, neck, shoulders, other small joints of the hands and feet, hips, ankles and mid-foot, sticking to the Beighton scoring method is not enough in clinical examination. A high degree of applied musculoskeletal expertise and knowledge of the condition will be required to address all the problems.

If someone has been diagnosed with hypermobility and symptoms of pain, it is advisable that particular care should be taken with physical treatments. Avoiding activities that would strain the hypermobile joints.

Treatments should focus on improving the functional stability and mobility of the soft tissue structures. Awareness such as perception of correct posture with neuro-muscular proprioceptive training. Maintaining an active lifestyle with lifestyle modification. Even simple things like nutrition and balanced diet to maintain optimal body weight will be beneficial.

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